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Sunday, April 12, 2020

Experts and Me

This is much too self indulgent for I am trying to understand what I think of the recent discussion of leaving things up to the experts. Donald Trump is making a very convincing case for leaving things up to experts by pretending to be able to outguess them using his gut. I remain not totally convinced.

I am definitely not willing to leave health care decisions to doctors. I am not talking about my own as I am generally healthy enough. I do insist on giving advice when is often to challenge doctors and argue with them about therapy. I am going to consider a typically good column by Michael Gerson here

The dangerous conservative case against expertise. He has a point. In particular, conservatives are often wrong when they disagree with experts (also when they are experts). Gerson happens to be my favorite conservative. I don't know how long he will remain a self identified conservative. I think he will follow his fellow Washington Post conservative quota hires Jennifer Rubin and Max Boot to neoliberalism.

He writes well enough that it is hard to quote.

I note here that he doesn't have an argument against medicare for all *or* for the claim that Covid 19 shows why it would be good

a human tendency to interpret disasters as confirmation of our existing beliefs. So the coronavirus outbreak proves the need for a border wall. [skip]”

Not every argument is strained or spurious. The pandemic has given our health-care system an X-ray, revealing disturbing racial inequities that need to be understood and addressed. But on the whole, we are right to be wary of people who claim great tragedies as the confirmation of pet theories and previous prophesies.

He just moves on, because his job is to be a conservative critiquing conservatives. I think there is also the point that it won't be enacted and so it isn't on the agenda. In particular he critiques

conservatives who look at the coronavirus outbreak and see, of all things, the discrediting of experts and expertise. In this view, the failures of the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) have brought the whole profession into disrepute. The judgments of health professionals have often been no better than the folk wisdom of the Internet. The pandemic is not only further proof of the fallibility of insiders; it has revealed the inherent inaccessibility of medical truth. All of us, scientists and nonscientists, are walking blindly on the same misty moor and may stumble on medical insights.

I think he is describing a real phenomenon and he is right to denounce it. But I have some criticisms.

First, and importantly, the internet is a medium. One can't discuss the effect of relying on the internet any more than of relying on the spoken word or books. He has something in mind, but he doesn't quite define it. I think he is thinking of social media of FacebookandTwitter. I get my opinions about Covid 19 and treatments from the internet, and, in particular from


Also I have read a lot about how the Wikipedia is unreliable, but know of only one gross error (the article on Ricardian equivalence).

I don't think it is possible to understand the problem without addresses the particular problem of the conservabubble. Think of edited media (the MSM). The reliability of edited news media sources varies widely. Don't trust Fox News. Don't trust the National Enquirer. Don't trust The Wall Street Journal opinion pages. Don't pretend that this is a general or symmetric problem.

My other thought is: What about the FDA ? It is, like WHO and the CDC a center of recognized expertise. It is also (unlike WHO) a center of power -- the FDA has legal authority. It has made terrible mistakes so far, and they have killed people.

In particular it is essentially 100% responsible for the delay of testing for Covid 19 in the USA. The CDC sent out test kits which had a (still not understood) problem. This would have caused at most a week of delay without the help of the FDA.

The problem appears to be with one reagent which should consist of a pair of oligonucleotides and which sometimes seems to be contaminated. I don't claim to understand what is wrong with it, but do note that it can be just left out, that the CDC test kits work fine if it is not used, and that this is one of the main ways tests are now conducted in the USA. Also all this was discovered about 1 week after the kits were mailed which was roughly 3 weeks after the Sars Cov2 sequence was published.

The further delay (roughly 2 weeks) occurred because the FDA did not authorize the use of the modified toss out the problem causing reagent test. It also placed a heavy burden for approval of tests by private agents -- hospitals, universities, and commercial testing firms.

That was the (more) fatal problem (in thousands of deaths caused).

I think there are two lessons. First there is a bias towards small c conservatism. A delay in adopting something new is always considered acceptable. This makes no sense. Another is that the expertise can be familiarity with the way things have been done (combined with the conservativism). Experts on Covid 19 testing include experts on RT-PCR and experts on obscure FDA regulations which implied that the declaration of an emergency slowed the response to the virus. The second group of experts (call them lawyers) know about current laws, rules and regulations. They don't know if they are optimal.

Notice that I haven't gotten close to saying that "medical truth" is inaccessible. One doesn't get there from questioning experts and especially not from questioning experts when they disagree.

OK I quote "And the CDC did badly mishandle the early stage of diagnostic testing." But what about the FDA ? Yes they made some mistake at the CDC, but it caused only a third of the total delay. Such problems are inevitable -- human perfection is impossible. But refusing to allow the correct solution to be used is not inevitable. By "solution" I mean solution with a solvent and solutes not including the powder which was supposed to be a pair of oligonucleotides (and may have been -- we don't know if it was contaminated).

another quote

Judgments based on that information are not infallible. But they are always preferable to the aggregate opinion of the Internet.

I am quite sure there is no such thing as the aggregate opinion on the internet. Again, he is thinking of something other than the medium. Again he ignores the fact that the peer reviewed literature is available on the internet (at least abstracts). I think he is on to somethng but the entity he has in mind is not "the internet". I'd call it "the conservabubble".

Gerson also leaves out experts. He notes the experts who warned of the pandemic and who advocated social distancing. He is right. He is also right that conservatives mostly dismissed them and that Trump is a disaster. In fact, I guess I agree with him about almost everything except his definition of "experts" and "the internet".

One aspect of the scientific literature is that extreme caution is favored. Guesses are not published (unless the person guessing is really famous). Claims to have found the answer are deliberately understated (which doesn't mean they aren't often wrong -- there is a constant struggle between the professional norms and the inclinations of enthusiasts).

But this is not appropriate as a guide for action in a crisis. The default response that we don't know and we have to do more research does not suggest what to do during that research.

The actual practice is to stick to business as usual. In medicine it is to stick to standard of care until and new therapy is proven to be superior (and the standard of proof is much stricter than the supposed proof beyond reasonable doubt which gets people locked up in prison). This makes no sense in the treatment of a disease first described 4 months ago. But it absolutely does describe actual choices made by actual doctors here "She listened patiently to Hall and expressed her concern that his suggestions did not conform to standard medical procedure or C.D.C. guidelines." The patient had Covid 19. How could there be standard medical procedure already ?

It is definitely a fact that doctors are very determined to define a standard of care (which is described in a document which in cases with which I am familiar is written by a private voluntary association of physicians). The reason for this is, I think, perfectly clear. If a patient is given care according to the standard, then bad outcomes do not imply malpractice liability. This means that sticking to the standard is sensible for the cautious physician who cares a lot about not being sued for malpractice and considers that more important than ding what, according to a posterior probability distribution updated with the available data, maximizes expected patient welfare.

This is the way it is done. The key experts include lawyers who explain malpractice liability (correctly).Then there are the standards of care, the official guidelines, whose key roles include defence in malpractice suits.

I assert that there is a problem here -- a moral problem and a policy problem.

I have been asserting this for years. As Gerson might predict, I now assert that the Covid 19 epidemic proves I was right.